Fecal incontinence: A clinical approach

''Fecal incontinence" is defined as the involuntary loss of stool at any ti me of life after toilet training. It is a socially and psychologically deva stating condition for patients and their families, and a topic which both p atients and physicians are reluctant to approach. Although the true prevale nce of fecal incontinence is unknown, studies have reported it to be as hig h as 2.2% in the general population, with significantly higher rates among nursing home residents and hospitalized elderly Risk factors include advanc ing age, female gender and multiparity. An understanding of pelvic floor anatomy and physiology is required to appr eciate hour diverse medical conditions can affect mechanisms involved in no rmal continence. The rectum serves as a storage reservoir until elimination can take place at a socially acceptable time and place. The pelvic floor m uscles help to regulate the defecatory process and maintain continence. The se muscles include the internal anal sphincter, the external anal sphincter and the puborectalis muscle. Each muscle contributes to normal continence, although the relative importance of each is controversial. Neurologic inte grity and sensation are also key factors. Conditions associated with fecal incontinence include diarrheal states, fec al impaction, idiopathic neurologic injury, surgical and obstetric injury, pelvic trauma, collagen vascular disease, and neurologic impairment related to stroke, diabetes, or multiple sclerosis. Evaluation of the patient with fecal incontinence includes a directed history and physical examination, w ith particular attention paid to integrity of the perineum and rectum and a complete neurologic evaluation. Diagnostic tools such as stool studies, an orectal manometry, defecography, electromyography, pudendal nerve conductio n, and endoanal ultrasound may be employed in an outpatient setting. Fecal incontinence may be treated conservatively by employing such methods as die tary restriction, stool bulking agents, and biofeedback Surgery may be the best option for cases refractory to medical treatment, or for those patient s with rectocele or obstetrical injury. In this article, we review the presentation, epidemiology pathophysiology a nd etiology of fecal incontinence. Evaluation, including key components of directed history and physical examination, and the appropriate use of diagn ostic studies and indications for treatment options are also addressed.